Citation Nr: A25106974 Decision Date: 12/11/25 Archive Date: 12/11/25 DOCKET NO. 250730-561327 DATE: December 11, 2025 ORDER Entitlement to an increased disability evaluation of 100 percent for service-connected malaria is granted. FINDING OF FACT The evidence of record is at least in approximate equipoise as to whether the Veteran's malaria was active during the appeal period on review. CONCLUSION OF LAW After affording the Veteran the benefit of the doubt, the criteria for an increased disability evaluation of 100 percent for service-connected malaria have been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.88B, Diagnostic Code 6304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the Unites States Marine Corps from May 1968 to February 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2025 rating decision that was issued by a Department of Veterans Affairs (VA) regional office (RO), Agency of Original Jurisdiction (AOJ). The Board notes that this appeal is the product of a long procedural history that initially stems from the Veteran's Notice of Disagreement (NOD) of an October 2018 rating decision under the legacy appeal system. In June 2020, the Veteran submitted VA Form 10182, Decision Review Request: Board Appeal, thereby opting into the modernized appeal system known as the Appeals Modernization Act (AMA), and selected the Hearing docket. Following a July 2021 Board hearing, a March 2022 Board decision remanded the claim of entitlement to a compensable rating for malaria to the AOJ for further development. Following multiple adverse AOJ rating decisions, the most recent of which was issued in September 2024, the Veteran filed another VA Form 10182 Notice of Disagreement in September 2024 in which he elected the Hearing docket. Following a Board hearing held on January 7, 2025, the Board remanded the Veteran's appeal of entitlement to a compensable rating for malaria for a legally adequate VA medical opinion. Following the evidentiary development, which notably included obtaining two VA medical opinions, the AOJ issued the July 2025 rating decision on appeal. In the July 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on August 21, 2025, a transcript of which is of record. See Hearing Transcript, dated August 21, 2025. Therefore, the Board may only consider the evidence of record at the time of the July 2025 AOJ rating decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Finally, this appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107; 38 C.F.R. § 20.800. Increased Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Similarly, separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). When a claimant's appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 126. Under the Appeals Modernization Act (AMA), a claim can be continuously pursued by filing an appropriate administrative review option to an AMA decision, generally within one year from when the decision was issued. If a claim is continuously pursued, it will be considered filed as of the date of the first claim in the continuously pursued chain, not the date the most recent request for review was received. See 38 C.F.R. § 3.2500(c)(h). Notably, for claims in which the review period occurs after the initial disability evaluation, relevant legal authorities dictate that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the evidence persuasively weighs against the claim, then it must be denied. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Entitlement to a compensable rating for malaria. The Veteran seeks a compensable rating for his service-connected active malaria or, alternatively, compensable ratings for the residuals of malaria if it is deemed inactive. See March 2018 VA Form 21-526EZ; Hearing Transcript, dated August 21, 2025. As discussed in greater detail below, the Board finds that the AOJ did not substantially comply with previous Board remand directives; however, in light of the fully favorable decision herein, any procedural deficiencies are moot. Stegall v. West, 11 Vet. App. 268, 271 (1998); Mlechick v. Mansfield, 503 F.3d 1340 (Fed. Cir. 2007). The Veteran has been service-connected for malaria since February 3, 1970. See Rating Decision - Narrative, dated May 7, 1970; Rating Decision - Codesheet, dated July 3, 2025. The Veteran was assigned an initial disability evaluation of 10 percent but has been assigned a non-compensable rating since February 3, 1971. Id. During the relevant appeal period on review - which began in March 2018 when VA received the Veteran's increased rating claim - the Veteran's malaria has been rated under 38 C.F.R. § 4.88b, Diagnostic Code 6304. Relevantly, the rating criteria for malaria were revised effective August 11, 2019. 84 Fed. Reg. 28227, 28230 (June 18, 2019). Prior to August 11, 2019, 38 C.F.R. § 4.88b, Diagnostic Code 6304 provided that malaria as an active disease was to be rated as 100 percent disabling. Thereafter, VA was instructed to rate residuals, such as liver or spleen damage, under the appropriate system. The Note for malaria stated "the diagnosis of malaria depends on the identification of the malarial parasites in blood smear. If the veteran served in an endemic area and presents signs and symptoms compatible with malaria, the diagnosis may be based on clinical grounds alone. However, relapses must be confirmed by the presence of malarial parasites in blood smears." 38 C.F.R. § 4.88b. If the malaria is inactive, residuals are to be rated, such as liver or spleen damage, under the appropriate system. Id. After August 11, 2019, malaria is evaluated using the General Rating Formula for Infectious Diseases. A 100 percent rating is assigned for an active disease, and a non-compensable (0 percent) rating is assigned after the active disease that has resolved. Any residual disability of infection must be rated within the appropriate body system. 38 C.F.R. § 4.88b, Diagnostic Code 6304. Note 1 for Diagnostic Code 6304 states that the diagnosis of malaria, both initially and during relapse, depends on the identification of the malarial parasites in blood smears or other specific diagnostic laboratory tests such as antigen detection, immunologic (immunochromatographic) tests, and molecular testing such as polymerase chain reaction tests. Note 2 for Diagnostic Code 6304 says to rate under the appropriate body system any residual disability of infection, which includes, but is not limited to, liver or splenic damage, and central nervous system conditions. Ultimately, the pre- and post-revision rating criteria for malaria under 38 C.F.R. § 4.88b, Diagnostic Code 6304 are functionally identical. The only difference as it relates to the Veteran's appeal is that the note to the pre-amendment criteria (that is, before August 11, 2019) stated that the diagnosis of malaria depends on the identification of the malarial parasites in blood smears alone; however, the post-amendment criteria allows for "the identification of malarial parasites" not only in blood smears, but also via "other specific diagnostic laboratory tests such as antigen detection, immunologic (immunochromatographic) tests, and molecular testing such as polymerase chain reaction tests." 38 C.F.R. § 4.88b, Diagnostic Code 6304. Factual Background The Board initially notes that there is significant conflict in the record as to whether the Veteran's malaria has been active, and if so, for what duration during the appeal period on review. See BVA Decision, dated March 19, 2025. Indeed, at the time of the Board's March 2025 remand decision, the record already contained opinions from at least five VA medical clinicians, with the Board's remand decision directing the AOJ to schedule another. See id. The first two examiners of record determined that the Veteran did not have malaria. In June 2018, B.D., M.D., determined that the Veteran did not have malaria at the time of the VA Infectious Diseases examination because the Veteran's service treatment records from January 1970 reflected a normal examination with no symptoms and because the Veteran's June 2018 common blood count (CBC) study was normal with negative malaria smears. C&P Exams, received June 13, 2018 and August 28, 2018. Dr. B.D. also cited studies stating, "P. falciparum malaria does not recur unless there was original treatment failure, which would have been evident within 28 days of treatment, or a new infection is contracted." C&P Exam, received August 28, 2018. In March 2020, A.O., FNP, conducted a review of the electronic claims file and determined that the Veteran's malaria was inactive based on negative malaria smears collected in February 2020. C&P Exam, received June 18, 2020. A.O. further determined that the Veteran's reported symptoms could not "be positively associated with his distant history of malaria." C&P Exam, received June 18, 2020. However, the clinician who administered the February 2020 hematology study referenced by A.O. cautioned, "One negative result does not rule out the possibility of parasitic infestation. If protozoal, filarial, or trypanosomal infection is strongly suspected, test should be performed at least three times with samples obtained at different times in the fever cycle." C&P Exam, received June 18, 2020. In March 2022, the Board remanded the issue of entitlement to a compensable evaluation for malaria and in so doing, stated, "Malaria is rated either as an active process or based on chronic residuals. For a rating as an active process, such must be established by blood studies." BVA Decision, dated March 9, 2022. The March 2022 Board remand decision further noted, "The AOJ did not obtain a medical examination determining the etiology of the Veteran's reported malaria residuals." Id. Pursuant to the Board remand decision, an April 2022 VA Infections Diseases Disability Benefits Questionnaire (DBQ) noted that the Veteran's April 2022 malarial blood smear was again negative; however, the examiner, S.L., M.D., opined that the Veteran's symptoms were attributable to malaria because contrary to Dr. B.D.'s assessment in her August 2018 Addendum Opinion, "P. falciparum malaria recurrence can, in fact, occur based on the following rationale: "Several articles have been written on the recurrence of falciparum malaria. []Malaria recurrence separated by more than 12 months is less likely to be due to P falciparum infection. []P falciparum malaria recurrence can occur by two different mechanisms: reinfection and recrudescence. Recrudescence with a long latency is the more likely explanation for this case, because reinfection usually occurs after day 14 of treatment[] and in endemic areas." C&P Exam, received April 29, 2022. In a June 2023 VA addendum opinion, Dr. S.L. clarified that the Veteran has active malaria as his symptoms have not been attributed to any other cause and he was not provided with repeat malaria tests to definitively rule out a diagnosis of malaria. C&P Exam, received June 25, 2023. Perhaps most importantly, Dr. S.L. raised the following concerns in the June 2023 addendum opinion: "I believe Veteran has active malaria [...] He has [symptoms] of malaria and no other cause has been documented. I have asked for repeat malaria tests, none has been provided, so no change in my rationale. The CBC on June 25, 2019 showed [values...] with[in] normal indices. These neither confirm nor refute the diagnosis of malaria. Malaria blood smear was negative 7/11/18. Also does not confirm nor refute because (diagnosis of malaria) because multiple specimens needed to refute." Id. Ultimately, neither Dr. S.L. nor the AOJ evaluated the residual symptoms of the Veteran's malaria under the appropriate body systems or diagnostic codes as dictated under 38 C.F.R. § 4.88b, Diagnostic Code 6304 as well as by the Board's March 2022 remand decision. In April 2024, the Veteran attended his fourth VA Infectious Diseases examination, after which examiner, M.W., PA-C, opined that the Veteran's reported symptoms were attributable to active malaria but, inconsistently, also opined that the Veteran had no residuals of malaria. See C&P Exam, received April 4, 2024. While M.W. noted that the Veteran's March 2024 malaria smears were negative, she also cautioned that "it is known in the medical community that chronic malaria infection with flares of the disease may show negative blood smears despite ongoing infection." Id. In May 2024, D.M., PA-C, authored a clarifying opinion of M.W.'s April 2024 DBQ and highlighted the same issue raised in previous VA Infectious Diseases DBQs and by the Board in its March 2022 remand decision as follows: "It is in this examiners opinion that the Veteran still presents with residuals of his previous malaria plasmodium falciparum even though Veteran has tested negative over the years. It is known that if the results of your malaria test are negative, it means that no signs of malaria parasites were found in your blood sample. But this doesn't rule out malaria. That's because the number of malaria parasites in your blood can vary over time. If you have a negative result, more blood samples are usually taken every 12-24 hours for a total of 3 sets of tests. If these test results are all negative, you probably don't have malaria. No other obvious cause has been found. It requires multiple blood tests to rule out malaria and this has not been done. In the absence of other causes, it is more likely than not that the veteran is experiencing relapses. The original diagnosis during the height of the disease took 18 blood samples to make the diagnosis, of which only 2 were positive. The lab report of 2018 suggests further sampling if clinical suspicion exists, and this has not been done. Repeat single lab on 4/18/2022 was the same, with the same recommendations." C&P Exam, received May 4, 2024. In September 2024, the Veteran was provided with a fifth VA Infectious Diseases examination, after which the examiner, B.P., D.O., determined that the Veteran's malaria became inactive in July 1969 and that it remained inactive with no attributable symptoms or residuals. C&P Exam, received September 7, 2024. However, the hematology study that underpinned Dr. B.P.'s opinion provided the same caution reflected in previous VA examination and hematology reports as follows: "One negative result does not rule out the possibility of a parasitic infection. If protozoal, filarial, or trypanosomal infection is strongly suspected, test should be performed at least three times with samples obtained at different times in the fever cycle." C&P Exam, received September, 4, 2024. Oddly, although B.P. included the aforementioned caveat verbatim in her DBQ, she did not discuss its relevance or otherwise address - or attempt to ameliorate - the concerns it raised. See id. In its March 2025 remand decision, the Board highlighted the conflicting VA medical assessments of record described above as to whether the Veteran has active malaria or simply residual malaria symptomatology. The Board determined that none of the preceding VA Infectious Diseases DBQs and Medical Opinions of record were adequate and that the AOJ failed to develop the record by obtaining the required blood studies recommended by VA examiners, or by rating the residual effects of the Veteran's credibly reported malaria-related symptoms. Pursuant to the Board's March 2025 remand, in April 2025, VA clinician, H.W., FNP-C, reviewed the Veteran's electronic claims file without an in-person evaluation but ultimately declined to provide an opinion. See C&P Exam, received April 6, 2025. In June 2025, VA examiner, D.B., NP, administered an in-person VA Infectious Disease examination of the Veteran and determined that the Veteran's malaria was active but, also, that the "[c]ondition is staying dormant with intermittent and periodical exacerbations." C&P Exam, received June 12, 2025. The record does not reflect that the AOJ scheduled a blood smear or any other study referenced in 38 C.F.R. § 4.88b, Diagnostic Code 6304. Following D.B.'s VA Infectious Disease examination and subsequent DBQ, the AOJ denied the Veteran's claim of entitlement to a compensable rating for malaria in the July 2025 rating decision on appeal. Rating Decision - Narrative, dated July 3, 2025 (determining, "A higher evaluation of 100 percent is not warranted for malaria unless the evidence shows active disease"). However, contrary to the explicit directives of previous Board remand decisions, the AOJ noted that "[h]igher evaluations may also be warranted based on residuals" but offered no discussion or determination of such. Id. At the August 2021 Board hearing, the Veteran testified that he continued to experiences malaria-related symptoms, such as periodic night sweats, fevers, headaches, tiredness, muscle and joint pain, anxiety, and tingling in the extremities. See Hearing Transcript, dated August 21, 2025; see also Hearing Transcript, dated January 28, 2025. Analysis After a careful review of the record and applicable legal framework, the Board determines that the evidence of record is at least in approximate equipoise as to whether the Veteran's malaria was active during the appeal period on review. Pursuant to the Board's March 2025 remand, in April 2025, VA clinician, H.W., FNP-C, reviewed the Veteran's electronic claims file without an in-person evaluation and ultimately declined to provide an opinion as follows: "To diagnose malaria, a physical exam is conducted, and blood tests ordered. [...] The lab report of 2018 suggests further sampling if clinical suspicion exists, and this has not been done. Repeat single lab on 4/18/2022 was the same, with the same recommendations. Hence, to make a definitive diagnosis of malaria, [further] investigations need to be carried. Veteran's malaria to be active or inactive cannot be determined, hence further investigation is required." C&P Exam, received April 6, 2025 (emphasis removed). Thus, by her own admittance, H.W.'s Infectious Diseases DBQ is inadequate for adjudication purposes following the Board's March 2025 remand decision. The AOJ requested another VA Infectious Disease opinion and in June 2025, VA examiner, D.B., NP, administered an in-person examination of the Veteran. See C&P Exam, received June 12, 2025. D.B. determined that the Veteran's malaria was active but, also, that the "[c]ondition is staying dormant with intermittent and periodical exacerbations." Id. The record does not reflect that the AOJ scheduled a blood smear or any other study referenced in 38 C.F.R. § 4.88b, Diagnostic Code 6304. Following D.B.'s VA Infectious Disease examination and subsequent DBQ, the AOJ denied the Veteran's claim of entitlement to a compensable rating for malaria in the July 2025 rating decision on appeal. Rating Decision - Narrative, dated July 3, 2025 (determining, "A higher evaluation of 100 percent is not warranted for malaria unless the evidence shows active disease"). However, contrary to the explicit directives of previous Board remand decisions, the AOJ noted that "[h]igher evaluations may also be warranted based on residuals" but offered no discussion or determination of such. Id. Regardless, D.B.'s opinions and underlying rationale are inadequate for adjudication purposes for multiple reasons. First, despite the issues raised in previous hematology reports and Board remand decisions regarding the importance of taking multiple blood samples, the AOJ did not appear to order a blood smear or "other specific diagnostic laboratory tests such as antigen detection, immunologic (immunochromatographic) tests, and molecular testing such as polymerase chain reaction tests." 38 C.F.R. § 4.88b, Diagnostic Code 6304. Second, and similar to the first issue, D.B.'s examination report does not discuss the most relevant detail required for a compensable rating under Diagnostic Code 6304 - that is, the identification of the malarial parasites in blood smears or other specific diagnostic laboratory tests. Third, under the old rating criteria - that is before August 11, 2019 - relapses for malaria must be confirmed by the presence of malarial parasites in blood smears. Similarly, note 1 of the post-amendment rating criteria for Diagnostic Code 6304 states that the diagnosis of malaria, both initially and during relapse, depends on the identification of the malarial parasites in blood smears or other specific diagnostic laboratory tests. Here, none of the VA Infectious Disease DBQs and Medical Opinions authored after the March 2025 Board remand decision remotely satisfies the specific and clearly delineated criteria for Diagnostic Code 6304 under either the old or revised version. Fourth, D.B. acknowledged the limitations in her knowledge of infectious diseases, which is evident in the highly speculative nature of her opinion as follows: "An accurate medical opinion in this case would ideally come from an Infectious Disease specialist with expertise in tropical medicine. Without that specific evaluation for the Veteran, I am unable to provide a correct estimate, which likely explains why the previous medical opinions contradict each other. My understanding is that P. falciparum can maintain a chronic, low-level infection." C&P Exam, received June 12, 2025. D.B. referenced numerous articles and medical theories but ultimately offered tepid or conditional, generalized, and highly speculative statements regarding recrudescence - the term for P. falciparum symptoms that appear many years or even decades later. Finally, the Board notes that the AOJ ignored D.B.'s opinions and simply determined that the Veteran's was not entitled to a compensable rating under Diagnostic Code 6304; however, the AOJ also declined to rate the Veteran's residuals of malaria as directed by previous Board remands. Based on the foregoing, the Board finds that there has not been substantial compliance with either the March 2022 or the March 2025 Board remand decision. The United States Court of Appeals for Veterans Claims (Court) has held "that a remand by this Court or the Board confers on the veteran or other claimant, as a matter of law, a right to compliance with the remand orders." Stegall v. West, 11?Vet. App.?268, 271 (1998). Consequently, compliance with the terms of the remand is necessary prior to further appellate review, and if not, "the Board itself errs in failing to ensure compliance." Id. Thus, under typical circumstances, the Board would be forced to remand the Veteran's claim for a new VA examination and medical opinion. However, at this juncture, the Board is loath to issue another remand with the same directives to obtain multiple blood smears - or other specific diagnostic laboratory tests - as described by the myriad VA medical examiners of record. Similarly, given that at least eight other VA medical clinicians have opined on the topic to no avail, the Board is skeptical that another VA Infectious Diseases DBQ will somehow be based on the appropriate clinical findings dictated by 38 C.F.R. § 4.88b, Diagnostic Code 6304 as well as an adequate, well-formed medical assessment of the Veteran's malaria, which has already been mandated by two other Board remand decisions. The record does not offer any indication as to why the AOJ declined to provide repeated blood smears or any other study referenced in 38 C.F.R. § 4.88b, Diagnostic Code 6304. However, the evidence of record makes it clear - even if not explicitly stated - that obtaining multiple blood samples every 12-24 hours was either impractical or impossible. See C&P Exam, received May 4, 2024 (stating, "It is known that if the results of your malaria test are negative, it means that no signs of malaria parasites were found in your blood sample. But this doesn't rule out malaria. That's because the number of malaria parasites in your blood can vary over time. If you have a negative result, more blood samples are usually taken every 12-24 hours for a total of 3 sets of tests. If these test results are all negative, you probably don't have malaria"). The Veteran, who faces numerous significant health challenges, has availed himself of every demand and scheduling requirement asked of him throughout the nearly seven-year period of his appeal. Thus, despite the imperfect evidence in this case, the Board finds that remanding to obtain better medical information would not only be unlikely to yield such, but in so doing, would likely not benefit the Veteran, especially considering his advanced age and health challenges. Accordingly, the Board will review the evidence of record available for consideration under the AMA. At the outset, the Board notes that the Veteran has credibly reported residual symptoms, which multiple VA examiners have attributed to his malaria. See Hearing Transcript, dated August 21, 2025; see also C&P Exams, received March 5, 2024, and April 4, 2024. However, the criteria for a compensable rating for malaria under the General Rating Formula for Infectious Diseases are highly specific and do not contemplate the frequency, severity, or limiting effects of specific symptoms. Moreover, the Board acknowledges that 38 C.F.R. § 4.88b, Diagnostic Code 6304 states that the diagnosis of malaria, both initially and during relapse, depends on the identification of the malarial parasites in blood smears or in other specific diagnostic laboratory tests. While the June 2018, August 2018, June 2020, and September 2024 negative VA opinions indicate that the Veteran does not have active malaria based on the absence of a positive test, they do not adequately address or offer an alternative etiology for his reported ongoing symptoms as repeatedly directed by the AOJ and by Board remand decisions. Moreover, none of the clinicians who authored the negative VA opinions discussed why they were able to arrive at their respective opinions even though the hematology studies that underpinned their rationale repeatedly cautioned that one negative test result was insufficient to rule out the presence of malaria. On the other hand, the April 2022, June 2023, April 2024, May 2024, and June 2025 positive VA opinions of record indicate that the Veteran has active malaria despite his negative testing, which is on its face inherently contradictory. Moreover, many of the positive decisions are speculative in nature in that they utilized conditional language indicating that the Veteran's that malaria "may" be present and cannot be "rule[d] out," "confirm[ed] or refute[d]." Similarly, the April 2022 VA opinion attributed the Veteran's symptoms to malaria but also indicated that the Veteran had no residuals of malaria. Finally, in the most recent VA Infectious Diseases DBQ of record, VA examiner, D.B., determined that the Veteran's malaria was active but, also, that the condition merely stayed "dormant with intermittent and periodical exacerbations." C&P Exam, received June 12, 2025. However, D.B. acknowledged her nescience on the topic and that an "accurate medical opinion in this case would ideally come from an Infectious Disease specialist with expertise in tropical medicine." C&P Exam, received June 12, 2025. The record at the time of March 2025 remand decision was truly in approximate equipoise with eight total opinions that were split evenly between positive and negative assessments as to whether the Veteran had an active disease process for malaria. D.B.'s June 2025 opinion, although imperfect, is the most recent medical opinion on the topic and was based on a thorough review of the medical evidence of record as well as the Veteran's credible lay statements. The Board also finds the opinions offered by Dr. S.L. in April 2022 and June 2022 particularly persuasive given that he provided the most authoritative and comprehensive discussion of relevant medical research relating to malaria of record. See C&P Exams, received April 29, 2022 and June 25, 2023. The Board also notes that Dr. S.L.'s opinion was considered inadequate in the March 2025 remand decision because Dr. S.L. - along with the AOJ - failed to evaluate the residuals of the Veteran's malaria as directed by the March 2022 remand decision. After careful review of the record and applicable legal framework, the Board determines that the evidence is at least in approximate equipoise as to whether the Veteran's malaria was active during the appeal period on review. In so finding, the Board relies heavily on the expertise of the medical professionals of record who provided the most compelling and persuasive discussion of the relevant malaria-related research and medical literature in juxtaposition with the facts and specific medical history of the Veteran. Moreover, the VA medical examiners who provided their positive opinions acknowledged their gaps in knowledge or the speculative aspects of their conclusions. By contrast, the negative etiology opinions relied upon negative blood smear results as, in of themselves, demonstrative of inactive malaria but offered virtually no discussion of notations within those same reports that said results were insufficient to rule out the presence of malaria. Accordingly, the Board determines that the reviewable evidence of record is in approximate equipoise - if not slightly tilted in favor of the Veteran - as to whether the Veteran had active malaria during the appeal period on review. (Continued on the next page) ? In conclusion, despite the imperfect evidence in this case, the Board will resolve all reasonable doubt in the Veteran's favor and find that the criteria for an increased rating of 100 percent for his service-connected malaria is warranted. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Cross, A. The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.